Provider Demographics
NPI:1447388129
Name:EATON, KELLI S (MS,,CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:S
Last Name:EATON
Suffix:
Gender:F
Credentials:MS,,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 E LAKE MARY BLVD
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32773-7125
Mailing Address - Country:US
Mailing Address - Phone:407-320-0657
Mailing Address - Fax:
Practice Address - Street 1:400 E LAKE MARY BLVD
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32773-7125
Practice Address - Country:US
Practice Address - Phone:407-320-0657
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA2909235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist